congestive heart failure & valvular disease
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Congestive Heart Failure & Valvular Disease. Keith Rischer RN, MA, CEN. Todays Objectives…. Review essential cardiac patho concepts Compare and contrast left-sided heart failure to right Describe special considerations for older adults with heart failure - PowerPoint PPT PresentationTRANSCRIPT
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Congestive Heart Failure &
Valvular Disease
Keith Rischer RN, MA, CEN
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Todays Objectives…
Review essential cardiac patho concepts Compare and contrast left-sided heart failure to right Describe special considerations for older adults with
heart failure Discuss the prevention of complications for patients
with heart failure Prioritize nursing care for clients with heart failure Identify common nursing diagnoses and collaborative
problems for patients with heart failure Evaluate the effects of interventions for reducing
preload and afterload through pharmacological management
Compare and contrast common valvular disorders
Introduction
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Definition of CHF Etiology
HTN MI
Left sided vs. Right sided Rt sided
COPD
Systolic vs. Diastolic Ejection Fraction
50-70% normal
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Cardiac OutputCardiac Output
CO = Stroke volume x heart rateSV (80cc) x HR (80)= 6400cc (6.4
lpm)
• Daily pumps 1800 gallonsDaily pumps 1800 gallons• 657,000 gallons every year657,000 gallons every year• Over 80 year lifetime:Over 80 year lifetime:
• 52,560,000 gallons52,560,000 gallons
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Definitions
Pre-load primarily venous blood return to
RA Right and left side of heart filling
pressure (atria>ventricles) Pressure/Stretch in ventricles
end diastole Stroke volume
Amount of blood ejected from the ventricle with each contraction
Systole Contraction; myocardium are
tightening and shortening
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Definitions
Inotropic state/contractility
Afterload: Force of resistance that Force of resistance that
the LV must generate to the LV must generate to open aortic valveopen aortic valve
Correlates w/SBPCorrelates w/SBP Diastole
Muscle fibers lengthen, the heart dilates, and cavities fill with blood
Patho: Patho: Starling’s Law of the HeartStarling’s Law of the Heart
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Maximum efficency of CO achieved when Maximum efficency of CO achieved when myocardium stretched appx 2 ½ times lengthmyocardium stretched appx 2 ½ times length
Think rubber bandThink rubber band CO decreased with lower preload/filling CO decreased with lower preload/filling
pressures or too highpressures or too high
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Compensatory Mechanisms in CHF
Increased Sympathetic Nervous System Stimulation
Renin-angiotensin system activation
Natriuretic peptides BNP
Ventricular hypertrophy
Acute Pulmonary Edema:
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Elevated capillary pressure within the lungs fluid pushed from circulating blood to interstitial tissues then to the alveoli, bronchioles, and bronchi
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Nursing Assessment:Left Failure
Dyspnea Cough Bilateral crackles Orthopnea PND Pulmonary Edema S3 (ken-tuck-ee) confusion fatigue and muscular weakness nocturia increase retention of sodium and water due to lowered
glomerular filtration edema
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Nursing Assessment: Right Failure
Dependent edema – early sign symmetric pitting edema Bedrest-sacral edema anasarca- late sign of CHF
Ascites Anorexia, nausea and bloating Cyanosis of nail beds Anxious, frightened, depressed Weight gain >2# daily
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Diagnostic Assessment
Chest x-ray Cardiac Enlargement
12 lead EKG Echocardiogram
assess ejection fraction
Labs BNP Liver enzymes…AST,
ALT Creatinine/GFR
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Acute Left Failure/Pulmonary Edema: Collaborative Management:
O2 treatment Drug Treatment
Diuretics Vasodilators-NTG MS Digitalis
Semi- Fowler’s position Frequent Heart and Lung Assessment Dietary Restrictions Planned rest periods Weigh daily Report to MD immediately:
persisting productive cough; dyspnea; pedal edema; restlessness
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Drug therapy:
Diuretics ACE Inhibitors Beta Blockers Calcium Channel Blockers Nitroglycerine Positive Inotropic agents
Digitalis
Beta Adrenergic Stimulator Dopamine,Dobutamine
.
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Pharmacologic: Diuretics
Mechanism of Action: Thiazides, Loop,
Potassium Sparing S/E:
fluid and electrolyte imbalances
CNS effects GI effects
Nursing Considerations:
Monitor for orthostatic hypotension
Hypokalemia
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Angiotensin Converting Enzyme (ACE) Inhibitors
Mechanism of Action S/E:
Hypotension cough Hyperkalemia…esp w/CHF, CKD, DM Angioedema
Facial/laryngeal swelling
Nursing considerations: Do not use with potassium sparing diuretic Metabolized by liver-excreted by kidneys
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Adrenergic Inhibitors:Beta Blockers
Mechanism of Action Recommended for initial drug therapy of
uncomplicated HTN (along with diuretic) S/E:
Orthostatic hypotension bradycardia bronchospasm
Nursing considerations: monitor pulse regularly
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Calcium Channel Blockers
Amlodipine, Diltiazem, NifedipineMechanism of Action:
S/E: Nausea H/A Peripheral edema
Nursing considerations: use with caution in patients with heart failure Orthostatic changes contraindicated in patients with 2nd or 3rd degree heart block Concurrent use w/b-blockers incr risk of CHF
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Vasodilators
Mechanism of Action-NTG
• Vasodilater-predominant on venous system by relaxing smooth muscles of vessels
• Dilates coronary arteries/improves collateral flow
• Up to 20% normal coronaries…30-40% pre/post stenosis
• Decreases LVEDP…why?
• Decreases O2 needs myocardium
Side effects
• HA, hypotension, tachycardiaHA, hypotension, tachycardia
HydralazineHydralazine
• arterial vasodilatorarterial vasodilator
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Priority Nursing Diagnosis
Impaired Gas exchange r/t ventilation perfusion imbalance
Decreased Cardiac Output r/t altered contractility, preload and afterload
Activity Intolerance r/t imbalance between O2 supply and demand
Knowledge Deficit Activity schedule Recognizing worsening heart failure Medications Diet therapy
Valvular Heart Disease:Mitral Valve
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Mitral Stenosis Patho
Mitral Regurgitation Patho
Mitral Valve Prolapse Patho
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Valvular Heart Disease:Aortic Valve
Aortic Stenosis Patho Causes
Congenital Atheroclerosis Calcification
Aortic Regurgitation (Insufficiency) Patho
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Treatment Valvular Disease
Non-surgical Management Diuretics Beta blockers Digoxin Antibiotics
Before any invasives Coumadin-if artificial valve
Surgical Management Balloon Valvuloplasty Open heart
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Pericarditis
Patho Open heart AMI
Assessment findings Friction rub CP w/insp CP relieves sitting up Global ST elevation
Complications Pericardial effusion Cardiac tamponade
pericardiocentesis
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Endocarditis Patho Etiology
Valve replacement Structural cardiac defects Invasive procedures
Clinical Manifestations New murmur Heart failure Embolic
Diagnosis Transesophageal Echo + blood cultures
Interventions IV abx Surgical